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Behaviors emerge, in part, from the interplay of infant abilities and caregiverinfant interactions. Crosscultural and developmental studies suggest caregiver handling and positioning influence infant development.
In this prospective, longitudinal study, the effects of 3 weeks of enhanced handling and positioning experiences
provided to 14 infants versus control experiences provided to 14 infants at 2 months of age were assessed
with follow-up through 15 months of age. Behaviors in prone were immediately advanced. Short-term
advancements occurred in multiple behaviors, including prone, head control, reaching, and sitting behaviors.
Longer term advancements, up to 12 months after the experience period, occurred in object transfer, crawling
and walking behaviors. This suggests broad and long-lasting changes can arise via brief periods of change in
caregiverinfant interactions.
The role of daily experience in the typical development of early behaviors is of interest to several
disciplines. For developmental psychology and
early education, studies that quantify the effects of
daily experiences provide an empirical test of key
theoretical principles of how infants gain the foundational skills for increasingly complex behaviors.
For example, this study tests the notion of embodied development, which states that developmental
abilities do not emerge de novo but emerge from a
rich history of exploration and daily interactions
between caregivers, young infants, and the physical environment (Adolph & Berger, 2006; Lockman, 2001). For pediatric rehabilitation, studies
that quantify the effect of caregiverinfant interactions provide an important foundation for new
assessment and intervention strategies and highlight the potential benefits of family-centered interventions (Bamm & Rosenbaum, 2008). The general
purpose of this project was to determine if a relatively short period of caregiverinfant interactions
would impact longer term changes in development.
Specifically, we aimed to determine the developmental consequences of a 3-week caregiver-provided enhanced handling and positioning program.
This research was supported in part by fellowships from The
University of Delaware and The Foundation for Physical Therapy.
Correspondence concerning this article should be addressed to
Michele A. Lobo, Department of Physical Therapy, 329 McKinly
Building, The University of Delaware, Newark, DE 19716. Electronic mail may be sent to malobo@udel.edu.
are in physical contact with young infants. Differences in handling practices across cultures have been
associated with differences in the development of
adaptive behaviors, motor behaviors, early communication, and cognitive development (Adolph,
Karasik, & Tamis-LeMonda, 2010; Bril & Sabatier,
1986; Hopkins & Westra, 1988). For instance, in
areas of Kenya, Nigeria, and West India, formal handling techniques to encourage sitting and walking
from birth have resulted in infants sitting and
walking months earlier than those in Western cultures. Non-Western caregivers using similar formal
handling techniques have infants with better head
control at 1 month and advanced sitting and standing at 6 months of age compared to infants born to
mothers not using such practices (Hopkins & Westra,
1989).
Young, immobile infants also spend considerable time being placed in positions by caregivers.
Descriptive studies suggest that greater experience
in multiple positions in the months after birth is
associated with better development in the 1st year
for healthy infants and those born preterm and at
risk for delays (Fetters & Huang, 2007). Reduced
experience in the months after birth in the prone
position, a position that is especially challenging
for young infants and that most caregivers avoid
or utilize very little, is associated with delayed
development in certain skills in the 1st year of life
(Kuo et al., 2008; Majnemer, 2007). Therefore,
theoretical and cross-cultural work suggests that
caregivers facilitate infants development through
their everyday handling and positioning interactions. This prospective, longitudinal, multiplegroup study specifically tested this proposal. Our
goal was to build upon these findings from across
cultures and within Western cultures to create an
enhanced handling and positioning program
aimed at advancing future development.
Process by Which Handling and Positioning Were
Expected to Affect Developmental Change
We expected a relatively brief period of enhanced
handling and positioning would have longer
lasting effects for two reasons. First, the altered
handling and positioning activities were expected
to advance infants foundational abilities that are
developmentally linked to future skills. For
instance, being placed in a range of positions
allows infants to experience a variety of possibilities for action, views of the world, levels of arousal
and social interaction, and postural and strength
requirements (Fogel, Messinger, Dickson, & Hsu,
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Method
Participants
Twenty-eight families with infants born full-term
were recruited from the local community at
2 months of age. Inclusion criteria were typical
development and no medical diagnoses. Twentysix of the infants were Caucasian and 2 were
African American. Caregivers provided informed
consent. Three additional families were excluded
from the study because they did not meet the minimum experience performance criterion (see below
for details).
Experience Groups
Infants were randomly assigned to either the
social experience (control) group or the handling
and positioning experience (experimental) group.
Infants were matched for gender so each group had
seven males and seven females.
Experiences were provided to infants by caregivers 15 min daily the first 3 weeks of the 60-week
study when infants were in an awake and alert
state. Caregivers were informed they could perform
the experiences in shorter segments throughout the
day if necessary to ensure infants remained in a
positive behavioral state during the activities. Caregivers received an illustrated manual and training
from an experimenter at the first study visit (see
Figure 1). They were given a diary to chronicle the
frequency, duration, and content of their sessions.
There was a minimum experience performance
criterion of 60% of the days for inclusion in the
study. Each participants diary was examined after
the prescribed home experience period and anyone
not meeting the 60% criterion was excluded from
the study at that point. The same experimenter, a
licensed pediatric physical therapist, trained all
families and conducted the visits.
At the second study visit caregivers were offered
the opportunity to ask questions, were asked to
demonstrate the home experiences without referring to the manual, and were offered any suggestions to improve the provision of the activities if
they deviated from the instructions. After the end
of the experience period (third study visit), caregivers were no longer required to perform the activities with their infants.
Social Experience (Control)
Caregivers in the control group were asked to
place their infants in supine and engage them in
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Figure 2. Caregivers in the social experience (control) group (a) were asked to place their infants in supine and engage them in face-toface interaction without objects for 15 min daily. Caregivers in the handling and positioning experience (experimental) group were
asked to perform activities for 15 min daily to encourage and assist pushing up in prone (b, c), pulling up and lowering down between
supine and sitting (d), maintaining head and upper body control in assisted sitting and standing (e, f), and moving hands to midline (g).
Appendix S2 for more detail). These activities provided enhanced perceptual-motor experience across
positions in order to promote abilities including
strength, postural control, and midline hand behavior. These activities also involved a fair amount of
social interaction between caregivers and infants.
Procedure
Assessments in the Home
The same experimenter, a licensed pediatric
physical therapist, visited families in their homes for
6 visits across the first 3 months of the study. The
average age of infants at each visit was 9, 10.5, 12,
15, 18, and 21 weeks of age (see Figure 1 for assessment schedule). There were no differences in the
ages of infants in each group at the start of the study
or at subsequent visits (age in weeks Visit 1: control
8.7 0.9, experimental 8.9 0.7; Visit 2: control 10.3
0.9, experimental 10.6 0.8; Visit 3: control 11.8
0.8, experimental 11.9 0.7; Visit 4: control 14.8
0.7, experimental 14.9 0.9; Visit 5: control 17.9 0.8,
experimental 17.9 0.9; Visit 6: control 20.6 0.8,
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Data Analysis
MannWhitney U nonparametric tests were used
to compare the two groups for all variables. Median
followed by minimum and maximum values in
parentheses and effect size using Cohens correlation coefficient (r) are reported for all comparisons,
with r = 0.10 representing a small effect, r = 0.30
representing a medium effect, and r = 0.50 representing a large effect (Cohen, 1992). One-tailed tests
were utilized for variables we hypothesized would
be different as a result of the experiences, such as
change in AIMS score after enhanced experience.
Two-tailed tests were used for the remainder of the
variables, such as age at the first visit. Only results
with significance values 0.05 are reported. To better describe these significant group changes, we
also report individual counts of behaviors. To test
the robustness of the findings, all analyses were
also performed using parametric independent sample t tests with Levenes test for equality of variances. The parametric and nonparametric findings
were consistent but the nonparametric findings are
reported here because many of the variables are
ordinal and our sample sizes are modest.
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Results
Groups Began the Study at a Similar Age and
Developmental Level
Infants were similar at the start of the study. All
infants were born full-term and there was no difference in weight at birth between groups. Infants in
each group started the study at the same age:control Mdn 8.4 (7.7, 11.0), experimental Mdn 8.7 (8.1,
11.2) weeks old, U = 72.50, ns, r = )0.22. There was
no reported difference in sleeping position of
infants (U = 82.50, ns, r = )0.22). The majority of
infants in each group slept in supine. Sleep position
differences between groups could have been an
important confound because motor development in
the 1st year of life may be delayed in infants who
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Discussion
Infants who received enhanced handling and positioning experiences at 2 months of age showed
advanced abilities that began immediately and continued through 12 months after the experiences.
Behaviors in prone were immediately advanced,
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kicking behavior occurs in supine and more handto-mouth behavior occurs in sidelying (Geerdink,
Hopkins, Beek, & Heriza, 1996; Rocha & Tudella,
2008). Changing head position with respect to gravity also provides a variety of visual and vestibular
experiences (Shumway-Cook, 1992). Experience is
important in the development of the visual and
vestibular systems as infants must learn to keep
their heads stable in order to receive reliable perceptual information (Pozzo, Levik, & Berthoz,
1995). Experience is also crucial for infants to learn
how to accurately perceive information from these
systems. For instance, when infants begin to
assume a standing position, this novel upright
experience allows them to adapt their otolithic
responses and sensitivities so they can detect movement of the body in planes not previously experienced through crawling and rolling (Bril & Ledebt,
1998). Therefore, experimental infants likely had
enhanced ability to detect and process perceptual
information across positions.
Changes in Caregivers and CaregiverInfant Interactions
The interplay between caregivers perceptions
and actions and infants abilities underlies the developmental process and was a focus of this study.
Even in the first months of life, typical development
involves a cooperative process of communication
and interaction between caregivers and infants as
infants facilitate and regulate their own learning
in conjunction with guidance from more experienced caregivers. Caregivers who are more sensitive
at reading infants cues and adapting their interactions to match infants abilities and needs have
infants with better social-emotional and cognitive
development at 12 years of age (Forcada-Guex,
Pierrehumbert, Borghini, Moessinger, & Muller-Nix,
2006; Treyvaud et al., 2009).
The changes we observed in infants abilities
most likely resulted from an interaction between
changes in infants abilities and in caregivers perceptions and interactions. Interestingly, caregivers
in the two groups reported different effects of participation in the study on their everyday interactions with their infants. Control group caregivers
reported greater social play and improved visual
attention for their infants, while experimental
group caregivers reported greater handling and
positioning play and improved strength and postural control for their infants. These reports suggest
that the changes in infants developmental abilities
were not simply the result of 15 min of isolated
experience across 3 weeks in time but that they
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were also the result of changes in caregivers perceptions and the everyday play interactions
between caregivers and infants that extended well
beyond the prescribed experience period.
Significance of the Findings
The findings of this study have important implications for developmental psychology and early
childhood education. First, they provide comprehensive support for the proposal that caregiver handling and positioning behaviors can instill broad
and long-lasting developmental changes. Second,
they provide additional empirical support for the
proposal that behaviors emerge, evolve, and
become increasing adaptive as a function of a complex history of experiences dependent upon the
interplay of infant abilities, caregiverinfant interactions, and environment. Third, they help us better
understand the complex process of development
and provide the foundation for more specific
hypothesis testing. For instance, many basic questions remain, such as what are the cues caregivers
respond to as they provide more advanced opportunities for their infants in development; what sources
typically inform and guide caregivers perceptions
about how to handle, position, and play with their
infants; and how does attainment of novel behaviors
such as reaching, sitting, crawling, or walking affect
daily interactions between caregivers and infants
and the structuring of their environment.
The findings of this study also have important
implications for medical professionals and early
educators working with populations with special
needs. The findings support that caregivers, their
interactions with infants, and the environment they
cocreate with infants are all critical components of
the developmental process and are important components of early assessment and intervention
programs (Wilder & Granlund, 2003). The findings
suggest early interventions should be jointly aimed
at educating caregivers and enabling infants
(Cotnoir-Bichelman, Thompson, McKerchar, &
Haremza, 2006). Therefore, the results support the
notion that a key component of early intervention
should be focused caregiver education targeted
toward advancing foundational abilities at developmentally appropriate times (Mahoney, Robinson, &
Perales, 2004).
Although the results of this study provide
important insights into development, limitations in
the design leave several questions open for future
investigation. First, participants enrolled in the
study by showing motivation to respond to recruit-
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Supporting Information
Additional supporting information may be found
in the online version of this article:
Appendix S1. Social Experience Manual.
Appendix S2. Handling Positioning Manual.
Please note: Wiley-Blackwell is not responsible
for the content or functionality of any supporting
materials supplied by the authors. Any queries
(other than missing material) should be directed to
the corresponding author for the article.